Counseling Young Cannabis Users by Text Message

Abstract

This article presents a study of 2 Short Message Services (SMS) aimed at providing young people with information on cannabis and helping them to reduce their consumption of the drug. The study is based on qualitative interviews with 12 young people. The attitude of the participants in the study towards the predefined messages is generally positive, but they prefer factual information to advice and counseling. The messages prompt reflection and awareness among the recipients, and their repetitive, serial nature plays a significant part in the process of change.The SMS services offer a less demanding, potentially less confrontational alternative to traditional forms of counseling and treatment. The article compares text message counseling with web-based interventions and telephone help lines.

Text messaging is part of an emerging wave of technology that allows consumers to get health information instantly through their mobile phones (Terry, 2008). Text messaging was first used in a medical context for making and cancelling face-to-face appointments (Anthony, 2006), but it has gone on to prove effective in self-monitoring and following-up roles in the treatment of conditions including diabetes, asthma, bulimia nervosa and psychiatric illness (Bjerke, Kummervold, Christiansen, & Hjortdahl, 2008; Robinson, et al., 2006). There is also evidence that text-message reminders increase patient compliance in taking medication for such diseases as tuberculosis and HIV (Group, 2006).

Text messaging is particularly popular among young people, and services have been developed targeting this group accordingly. As early as 2002, a UK charity launched an information service providing young people with sexual health information and support by telephone, Internet, and text message (Kinkade & Verclas, 2008), a similar service exists in the US (Levine, McCright, Dobkin, Woodruff, & Klausner, 2008). In Spain, Finland and Denmark, text messaging is now used with the aim of preventing drug abuse amongst young people¹.

Text messaging could prove to be an innovative way of reaching young people, but little is known about the actual effects of the text messages or the ways in which they are received. This article presents a study of an anonymous support and counseling project for young cannabis users intended to reduce the harmful effects of the drug and to provide them with information and support. In Europe and America, cannabis is by far the most commonly used illicit drug, and use of the drug is disproportionately high among young people (NIDA, 2006; EMCDDA, 2008). The project is centered on subscription to two SMS packages. The article will show how the young people received and used the two services, and the ways in which they profited from them in terms of changing their drug-abusing behavior. Furthermore, the article will explore the participants' views on how the SMS services compare with traditional forms of counseling and treatment. Before moving on to empirical areas, the article gives a brief overview of the literature. Given the paucity of studies on text message counseling, the review will focus on literature on web-based anti-drug interventions and literature on counseling supplied by telephone.

Mediated Antidrugs Interventions for Young People

A number of innovative programs have attempted to exploit new tools of communication in order to engage with young cannabis users. Especially the Internet has established itself as a key medium for anti-drug interventions. In addition to basic sites for information provision, a number of clinical applications can been found for the web, featuring more complex and interactive health interventions and treatment programs: drug self-tests, interactive diaries, phone/e-mail/chat contact with a counselor, preprogrammed software packages with little or no direct therapist involvement, etc². There is a significant target audience for such interventions. Drug treatment demand has risen, particularly among young and socially integrated cannabis users (Leuschner, Tossmann, & EMCDDA, 2009).

In general, little has been done to examine the efficacy of the Internet-based drug treatment programs in leading to changes in substance use behavior (Copeland & Martin, 2004). An exception is the evaluation of the German “Quit the Shit” initiative, an online withdrawal program with an interactive diary for juvenile cannabis consumers: 32 % of participants were reported as abstinent after completing the program (Leuschner, et al., 2009).

While the literature on Internet-based substance use interventions is sparse and flawed, the potential impact of effective intervention is considerable. In the US alone, among the 90% of all 15–24 year-olds who have ever gone online, three out of four (75%) have used the Internet to find health information. Among these 75%, 4 out of 10 say they generally find online health information “very useful”, and 4 out of 10 say they have changed their personal behavior because of health information they got online (Rideout, 2001). Additionally, there is an increasing body of evidence indicating that using text to conduct a clinical or therapeutic relationship is not only possible but in many cases more desirable, from the points of view of clients and practitioners alike (Horton & Feltham, 2006). Online services are convenient and flexible, and attractive to clients who wish to remain anonymous (Hunt, 2002; Skinner & Zack, 2004). Also, written information can improve health knowledge and information recall, and alternative-format resources such as e-mail and chat can improve health knowledge, user satisfaction, self-efficacy and health behavior (Colledge, Car, Donnelly, & Majeed, 2008).

A more established medium for counseling is the telephone—the telephone has been acknowledged for over 40 years as having a role in providing help at times of crisis (Anthony & Goss, 2003). Smoking cessation help lines have been empirically shown to increase abstinence (Lichtenstein, Glasgow, Lando, OssipKlein, & Boles, 1996; Meites & Thom, 2007), but very few studies exist of the utility of drug abuse help lines. One study found that concrete therapeutic advice over the phone was highly rated by the callers, while drug abuse help lines that almost exclusively served as referral agencies or gave written information were not helpful (Hughes, Riggs, & Carpenter, 2001). Overall, telephone counseling can have many advantages over face-to-face counseling, some of which are shared with Internet counseling. Telephone counseling is convenient and may allow for more privacy and confidentiality, and the anonymity of the medium is liberating for many (Rosenfield, 1997). By giving clients a greater feeling of control, the telephone may also allow clients to be more relaxed. Many people are uncomfortable talking about their personal problems while in the physical presence of another person, and may be more forthcoming when they cannot be seen (Rosenfield, 2003).

Talking on the phone differs in obvious ways from text-based communication on the Internet. Tone of voice, pitch, pauses, and breathing are key tools aiding listening and understanding in a telephone call (Hopper, 1992), but the writer of a text message must convey meaning without these. In return, unlike a telephone call, texting offers the choice of meeting out of real time. This asynchronous communication (Frehner, 2008) does not require on-the-spot responses; there is time to think and evaluate. In this way, texting creates a flexible temporal space in which interaction can be stretched out or shortened as required.

In sum, though little is known about mediated antidrug interventions, there is evidence that counseling supplied by Internet and telephone can be efficient and appropriate. Internet and telephone counseling both resemble and differ from another. The Internet and the telephone can be used privately to access information anonymously, but talking differs in several ways from writing. Next, we look at the general popularity of the mobile phone and it is discussed how text messages compares with the telephone and the Internet.

The Mobile Phone, Text Messaging, and Young People

Even before the massive success of the mobile phone, young people had a special relationship with the telephone: “the child and the teenager understand the telephone, embracing the cord and the ear-mike, as if they were beloved pets” (McLuhan, 1967, see also Keller, 1977; Liede & Ziehe, 1983; Skelton, 1989). For young adults today, close to two-thirds (62%) say it would be very hard to do without a mobile phone, more than the half (51%) who say that about the Internet (Horrigan, 2008). Approximately 79% of all teens have a mobile device—a 36% increase since 2005 (Lejnieks, 2008). Such widespread and growing availability presents a unique opportunity for broad dissemination and improved access to interventions for substance use problems.

Technological affordances (Hutchby, 2001) render the mobile phone environment very different from the environment in which landline phones is used. While landline phones are associated with specific, fixed locations, mobiles afford mediated interaction unanchored to previously specified geographical locations. With the mobile phone, therefore, participants may interact anywhere and at any time. Also, unlike a landline phone service, the mobile line is rarely shared (Hutchby & Barnett, 2005). This may allow for a high degree of privacy, since it is the known owner of the handset, and not anyone else who may happen to be in the vicinity of the phone, who receives the call. Compared with computers, mobile phones are small and can be carried around easily, and the diminutive screen allows for secret communication, even in groups of people.

So, offering counseling to young drug users via text messaging could have a number of advantages. The mobile phone is now more popular than the Internet, and the fact that mobiles are small and can be used privately to access information anonymously and quietly makes text messaging an obvious, feasible and culturally acceptable way for young people to receive information. Since confidentiality is one of the most important concerns for young people seeking health information online (Rideout, 2001), text messages could connect to young people who either do not dare to contact the world of adults, because they risk one sanction or another owing to their drug abuse, or others who do not define themselves as needing help. These users might perceive counseling via the mobile phone as unthreatening because it is possible to stay anonymous and get information to verify or discredit their concerns about their drug use.

Material and Mode of Approach

The combination of mobile and Internet technologies raises a host of possibilities for innovative applications and new modes of interaction. An example is the SMASH program treated in this article. The project is based on text messages, thus is not really Internet-based. However, the registration can be conducted via the projects' website where further information about the program can be found. The website also provides a drug self-test. The project is centered on subscription to two SMS packages. The first of these (Hashfacts) provides factual information about cannabis use; the second (Restart) offers support and motivation to those attempting to give it up. SMASH offers other SMS services such as Room (group messages where four users can connect), Coach (dialogue with a professional counselor), and Hashlex (a lexicon).

The project was developed in Denmark cooperatively by the prevention department of the drug abuse centre of West Sealand County and the Frederiksberg Drug Treatment Centre. The project grew out of positive experiences with internet-based drugs counseling. These experiences indicate that it is possible, via the Internet, to establish a dialogue with young people who would not go to a drug abuse centre yet have nowhere else to go. Internet counseling can help users, if not with a cure then to a greater understanding of their situation (interview with project leader Flemming W. Licht, June 2005). The first version of the SMS services was tested in connection with talks on drugs aimed at young people in high school. The tests revealed a need for technical adjustments, but the young people said that they got something to think about, which they did not get during the talk (interview with project leader Flemming W. Licht, June 2005). The improved version, treated in this article, was launched in March 2005 supported by an information campaign in selected cities.

The focus of this paper will be on the two predefined packages with no direct counselor involvement. The first service, Hashfacts, consists of 40 text messages about cannabis sent over 21 days. The messages are sent at 7.45am and 6pm every day. Examples of Hashfacts messages are:

When you smoke a lot of cannabis, you become poorer at navigating the social world, and less interesting to other people.

Young people who stop smoking cannabis after many years of using often find that they have not developed in the same way as other people.

When you smoke cannabis, you often find routines disappear, and everything revolves around cannabis. Just getting out of bed can seem an insurmountable task.

Those who smoke a lot of cannabis often find it difficult to have a conversation unless they are stoned. They know themselves best when they have smoked.

It can be hard to be a part of a group of friends who smoke cannabis without smoking yourself.

A month after you stop smoking cannabis, you will find that you feel more fresh and awake, and that both language and memory are reappearing.

This is the last message. It's been good to have you on board. Good luck with the rest of your life. If you should need us, you know where we are.www.smash.name.

The second service, Restart, is for those who want to smoke less. It consists of 68 text messages delivered over 36 days. The first 10 messages arrive once a day, at 8am. After that, there are two or three messages a day, divided into four phases with different goals, as formulated by the project leader, Flemming W. Licht (Laursen, 2007):

• Phase 0: Goal: motivation. Focus on clarification of abuse together with information regarding the next step towards reducing or stopping cannabis abuse.

• Phase 1: Goal: working on the anxiety and chaos detoxification creates. Helping the cannabis abuser to resist the desire to retire once more behind the screen of cannabis. Retraining established modes of thinking so new skills and insights are possible. Breaking down the cannabis abuser's pattern of use and helping them to see patterns between their level of functioning and the scale of their abuse.

• Phase 2: Goal: the young person must be able to tell a difference between current level of possibilities and future perspectives. They must become motivated to find a new identity and become negatively disposed towards their old, cannabis-abusing identity, understanding that cannabis hampers their abilities and positively visualising the future.

• Phase 3: Goal: full development of a new identity. Having lived with their new identity for only a short time, the cannabis abuser has yet to break fully free of their old, drug-using self.

Examples of Restart-messages are:

Phase 0: Think about how much cannabis you have smoked in the last week. Which times have been important for you, and which could you have done without?

Phase 0: Do you smoke less when you have to do something important the next day? Think about whether you smoke as much as you would like without considering what you have to do the next day.

Phase 1: Decide that you will smoke less today, and only today. Take one day at a time. That way, you will be able to keep a better perspective on the situation.

Phase 1: Did you try to smoke less today? How did it go? Have you noticed situations in which you used to smoke but have not done so?

Phase 2: Think about three positive things that have happened to you since you changed your cannabis-taking. Write them down and put them on the wall. Read them several times a day.

Phase 2: Did you write down three positive things? You can also text them to 26169988. And you can go at any time towww.smash.nameto read your statements and those of others.

Phase 3: Think about how you are going to tell your old smoking buddies you don't do drugs any more.

Phase 3: Think about the arguments you will use when your friends asks you why you don't want to smoke any more. Look at some of the things you have texted us.

Contact with the young people in the two services is based on taking an experience-oriented, humanist approach to counseling. This means it is crucial that there is a common understanding between user and counselor, while the counselor at the same time seeks to further the user's potential for growth, self-determination and freedom of choice. The approach is founded on a faith in the human capacity to reflect, thus creating new consciousness and new meaning. This becomes the basis for change in the user. The counselor gives no prepackaged solutions, but rather seeks to focus on the user's own ability to solve his or her problems.

The approach is also inspired by the principle of “harm reduction,” with the goal of mitigating the dangers and health risks associated with drug abuse. The long-term goal may indeed be to stop taking drugs, but the goal in view here is short-term and more realistic, and stops short of total abstinence. The reduction-of-damage approach foregrounds respect for the user and an acceptance of the user's decision to use drugs (though without necessarily supporting this choice).

Method and Informants

The study of the two services is based on qualitative interviews with 12 young people who have tried either Hashfacts or Restart. Interviews are particularly useful for getting the story behind a participant's experience (Kvale, 1996). The 12 were selected by contacting all registered users of Hashfacts and Restart in March, April and May 2006, a total of 376 users. Users were contacted via text message, and 32 responded positively to participate in the study. Subsequently, a telephone interview was conducted to single out who belonged to the project's target audience and had a genuine interest in participating in the study. Also, the participants had to be able to express themselves and hold a conversation.

The interviews were conducted shortly after, one person at a time, a public place which they chose. The interviews were semistructured, allowing new questions to be brought up during the interview as a result of what the participant says. Each interview lasted approximately 1 hour and consisted of open-ended questions concerning the informants' history of substance abuse, their use and reception of the service, and their views on how the service compared with traditional forms of counseling and treatment. The interview data was collected in collaboration with project staff.

By the author, data was transcribed verbatim and in detail, and inductive coding was made. First, an initial reading generated a variety of categories created from meaning units or actual phrases used in specific text segments. Next, a focused coding was made reviewing categories, eliminating less useful ones, combining smaller categories into larger ones, etc. (Berkowitz, 1997; Bogdan & Biklen, 2007; Lindlof & Taylor, 2002; Lofland, 2006). No specialist software was used during the coding process.

For most of the interview group, the motivation for using Hashfacts/Restart was that they sought to maintain a reduced level of cannabis use, to cut their consumption or to give up the drug altogether. The group is weighted towards those whose use is recreational. Karsten is typical for this group:

Karsten: I used to smoke two or three times a week. In that period, I would smoke on weekdays as well; now I only smoke at weekends and during the holidays. And I have practically not smoked during the Easter holidays.

Interviewer: Only during social situations?

Karsten: Yes, while sitting at a mate's and drinking a little.

Nine of the 12 in the interview group are recreational users like Karsten, two are former abusers who at the time of the interview no longer used cannabis, and one is a cannabis addict. This mean that this study mainly deals with young people who abuse cannabis regularly, or have done so in the past; none in the group has not tried cannabis (nonusage), or used it only occasionally (experimental usage). All were accustomed to text messaging, using it every day for contact with friends and relatives.

Next, in the empirical part of the article, I will show how the young people received and used the two SMS services, and the ways in which they profited from them in terms of changing their drug-abusing behavior.

Reception

The Text Message as a Communication Tool

In the interviews, most participants stated that the idea of providing information and counseling via text message was essentially a good one:

Charlotte³ : I actually believe it's a really good way to approach people, because you use the phone all the time.

In the quote, Charlotte highlights the fact that the mobile phone is an everyday medium in general use. So the participants' positive reception of the services is closely related to the mobile phone's functionality, and to their use of it. For example, the participants ascribe to the product positive associations about functionality, ease, availability and discretion:

Line: The good thing about receiving it on SMS is the fact that you can read it when you want, and if you do not feel like reading it, you can always erase it.

Gert: It is just easy. You just receive it on the phone. You almost always have your phone on you.

Peter: It is better than a phone conversation, because there you need time, but with an SMS it can happen during the day.

Furthermore, many of the participants conceive of the text messages as being aimed at them personally. The mobile phones are, for most people, a personal possession, and that creates the framework within which an approach can be thought of as personal:

Kasper: […] it's more personal, when is it an SMS and not a phone call. Because then it is on your phone, and you are forced to read it. I think you tend to think more about an SMS, when it is aimed at you personally, than a commercial on TV, which you tend to forget again.

Peter: It was pretty good because it was like they were meant personally for me. They were not meant for the whole of Denmark, but only for me. So I, like, got it all for myself.

Lasse: You know it is some stupid machine that sends them out, but it is still on your phone […] it is not just some anonymous information, which stands over there. It is inside your phone, and then you relate to it […] An advert on a bus, for example, has nothing to do with me: that's there for other people's sake. The SMS is different because it comes directly to me.

In the quotations, the text messages are compared with approaches in mass media such as TV and posters on buses, which you tend forget about again (Kasper); which are meant for the whole of Denmark (Peter); and which have nothing to do with me, they are there for other people's sake (Lasse). The text messages, by contrast, are thought of as personal messages you get for yourself, and you pay more attention to them than you would to a mass message.

The participants' reception of the messages seems closely interlinked with their everyday activities and routines:

Karsten: The time of day, I think, was really well chosen. Because it was, like, pretty early in the morning we got one. Then you had time to check it before you went to school. And then there was one in the evening. It was appropriate that you got it at a time when you were sure you were not doing anything.

Lasse: I mean, it's in the morning that you smoke, and it is in the evening that you smoke. That means that before you light your morning joint, there is an SMS. And the same happens in the evening. That actually makes pretty good sense.

Peter: It was very nice. You got it in the morning, just after eating breakfast, and then you got it in the afternoon, so it was there every time you checked your phone.

The extracts show how the participants seek to fit the messages into their everyday life routines, such as meals, sleeping, school and smoking. It is also worth noting that several indicate that they like the stability of knowing the times when the messages are transmitted:

Lasse: Once I turned on my mobile phone in the morning, then there was that bip-bip. That was actually pretty cool. Because then you know, like, it is that.

Peter: It was, like, the first days, where you discovered how many messages you received, when you had enlisted, then it was just, ‘Oh, no’. But after a few days, it was fine, you got used to it.

The series of messages and the regular times of transmission could risk creating text-messages fatigue, meaning that the messages would never be read. But the quotations above indicate that regularity of transmission has more advantages than drawbacks for the participants: they know who is writing, and they are able to choose for themselves when they want to read the messages.

In conclusion, the SMS medium offers a potentially new way to help young people with their cannabis abuse. It is personalized, discrete, flexible, age-appropriate, and independent of location. The young people see the messages as being intended for them personally, and they pay more attention to them than they do to mass approaches such as broadcasts on TV. It is also possible to fit the messages into the everyday routines of life, thus providing the participants with a greater feeling of self-control.

Information Versus Counseling

While the participants were generally positive towards the text messages as a new communication tool, there was a crucial difference between the ways in which they received Hashfacts and Restart. With its daily messages dealing with the facts of cannabis, the Hashfacts package was welcomed very positively; the Restart package, however, with its messages centered on helping the young people to reduce their abuse of cannabis, was far less favorably received. The difference seems to be closely linked to the different content and modes of approach of the two services.

The participants were generally positive towards the contents and the mode of approach in the Hashfacts messages:

Kasper: They were easy to read, so that was good.

Gert: I think that's fine: very short, and then you read straight through it, and you have already understood the message in it, or what it was […] That was straight forward.

Anton: The messages were very normal, very, like, neutral.

The interviewees focus on the simplicity, straightforwardness, and the intelligibility of the messages. The messages' hard, factual nature makes them easier to read and to understand. It is also evident that the messages' contents do not have an especially high level of news value for the participants:

Line: Well, it was very nice to get some information regarding hash, and some of the messages had some things I didn't already know.

Kenneth: I think it was really good. I was smoking cannabis right until when I signed up, and I thought it helped me a lot to be reminded about all the bad things the cannabis did to me.

So, some of the information was new, but most was not. Still, many of the participants were happy with the messages, which refreshed and supplemented their knowledge. Some of the participants did not even appear to focus on the contents at all, but more on the mere fact that the messages were being delivered:

I: You said it was too short? […] Should it have continued with the same type of messages? Shouldn't it have changed?

Gert: They might as well just have sent it again …

I: So … ?

Gert: Yes. You know, just so you have something to relate to. It helps you.

Line: Is it possible [to enlist again] so that it will reappear? […] Just so it keeps going. Then I have something to be guided by.

In the extracts, the participants say it would have been nice if the messages had started again: You know, just so you have something to relate to (Gert); Just so it keeps going. Then I have something to be guided by (Line).

The Restart package, with messages involving help to reduce abuse of cannabis, was not nearly as well received as Hashfacts. As shown in the previous section, the participants' overall attitude towards Restart was good, but the mode of approach and the content of the messages came in for criticism:

Asbjørn: My first experience of it was …the way it tries to communicate in a more abstract and sort of academic way. I don't know if I can find an example. “What advantages are there for you about smoking? What advantage do you think there will be about not smoking? Find three advantages and compare them.” Well, hello-o? We are talking about a super stoned, super desperate individual who is either smoking or trying to quit […] To get through, I think you have to use much more direct language, with some really hard examples that really appeal to the smoker's language. Like,“When was the last time you got laid?” Or, “Do you know that feeling of being afraid to look people in the eye?”“Aren't you tired of it?”“Come on - pull yourself together.”“How much of your life do you want to waste in front of the water pipe, honestly?”

Asbjørn talks about the mode of approach in the Restart messages as being too academic and abstract, and suggests that it should be more concrete and to the point. Furthermore, Asbjørn recommends using smokers' language. He provides a couple of examples, such as Aren't you tired of it? Pull your self together, and How much of your life do you want to waste in the front of the water pipe, honestly? These examples are out of line with the project's intended tone of just, even communication, because the wording is negatively loaded and judgemental. Nevertheless, Asbjørn is probably right in the fact that the messages are too soft in their approach. While the Hashfacts messages are very direct in their formulations, the Restart ones are full of formulations such as think about, try to, and consider whether: The voice is amenable, inoffensive and understanding. Also, a conversation is postulated with formulations including Have you noticed situations in which you used to smoke but have not done so? and Did you try smoking less today? How did it go? Such questions give the impression of an interaction that is not there, and can seem patronizing. Combined with small assignments (Write down three things …), they create the atmosphere of a student-teacher relationship at school.

Furthermore, the idea of the Restart package seems poorly defined for participants:

I: Why did you choose Restart? Why did you choose that package?

Robert: I think that was a random decision.

[…]

I: Then you have to, like, stop smoking cannabis. You have to reduce it afterwards. Did you follow that, or did you feel that you followed it?

Robert: No, I mean … no. I actually had not thought about that. That that was the point. […]

With the Restart messages, the participants must follow the phases. The process is part of the package. This means, for instance, that they must decide to smoke less at the time of the 12^th message, which is the start of a new phase. But in terms of content, the aim of the package is unclear for the participants, and they find it difficult to orient themselves towards the phases. The package has been built on a predefined progression that takes no account of discordant factors arising from the participants' actual situations, including any relapses.

Finally, those who had received the Hashfacts messages were especially negative towards Restart:

I: Would you sign up for Restart?

Charlotte: No, I don't think so.

I: Why not?

Charlotte: I have an issue with counselling nonsense. Sometimes I just don't believe them like 100%. It is probably just an attitude thing, which can be a stupid attitude. It's a thought I have. I don't think it will work.

I: Do you think it would be good for you to try?

Gert: No, not if they describe what you have to go through. It's like […] Well, I don't know. You actually have to change your circle of friends if you want to get away from it.

In the quotations, Charlotte and Gert show they doubt whether a program in the Restart mould could have any influence. As regular cannabis abusers, both are part of the Restart target group.

To sum up: With its daily messages addressing the facts of cannabis use, the Hashfacts package was very positively received. The participants were especially satisfied with the concrete mode of approach and the straightforwardness of the messages, and they were happy about the content, since this partly gave them new information while at the same time supplementing their knowledge and calling it to mind. The Restart package, however, with its messages aimed at helping smokers reduce their cannabis intake, was not nearly so well received. The participants' overall attitude towards the product was good, but the mode of approach and the contents were criticized. The overall mode of approach in Restart is soft, pedagogical, and understanding, and participants reacted against this. As regards content, the purpose of the package was not clearly defined, and participants had a hard time relating to the different phases of the package.

Effects

Less Cannabis?

The criterion for the success of the project was not that it made the participants stop or even reduce their cannabis abuse (interview with project leader Flemming W. Licht, June 2005). Nevertheless, many participants stated that the messages had indeed had such effects on their pattern of cannabis abuse:

I: Has there been a change in your cannabis abuse since you signed up?

Niklas: Yes.

I: Yes, there has. OK. How?

Niklas: Well, I don't smoke less. I mean, it is not that much less […] It is more seldom now, after the messages.

I: OK.

Niklas: Yeah, once a week or something like that.

I: OK. How often did you used to smoke?

Niklas: It was almost every day.

I: What happened? Was it because you enlisted for the messages, or was it because … ?

Niklas: Yes, and then I heard all kinds of things - read a bit on the Internet and stuff like that.

I: What about your girlfriend: Does she smoke at all?

Niklas: No. She has said I can't touch it. So that is also one of the reasons. Because I love her, right? And at the same time, I had a project about cannabis in school.

In the first part of the extract, Niklas says the messages played a central role in his smoking less cannabis. When the interviewer goes into details, however, it turns out that other factors also came into play: Niklas has a girlfriend, who encouraged him to stop; he sought information about cannabis online; and he did a project about cannabis at school.

Niklas is typical of the recipients of the SMS messages, in that he is in a process of transition. The messages played a role in the process, but it was not a central one. The common factor among these recipients is that, before signing up for the messages, they had already started this process of change. So the messages had an impact on cannabis abuse only when they were operating in conjunction with other agents. It is therefore possible to say that the messages contributed to maintaining and expanding a motivation that the participants already had for other reasons. In the following section, we look at the significance the messages had from the point of view of the participants.

Reflection and Small Pushes

First and foremost, the messages from Hashfacts and Restart contributed to the participants' reflections about cannabis:

Robert: When those messages started arriving, well, then I also started thinking a bit more about it when I got home. And so […] it's OK that you just get a message and then you start to think a bit about what it is you are doing.

Niklas: That thing about alcohol, where there was one … I don't remember what it was. It was somebody who smoked cannabis. There were 420 or so. What the fuck?⁴

I: Yes. So that could start a thought process?

Niklas: Yes. It was something I thought about all day, actually.

I: And you felt you could learn something from the messages you received?

Anton: Not, like, learn, but maybe start thinking. Even though it was stuff you knew in advance […] you just start thinking, right?

The participants in these extracts say they have started to think more about their abuse, that the messages have started a process of thought, and that certain simple messages lodged in their minds for a long time. Also, even those participants who say they received no new information still indicate that the messages got them thinking (Anton).

For the majority of the recipients of the messages, consideration and reflection are crucial factors; and the way the SMS service works on a daily basis seems especially conducive to these qualities:

I: Do you think the message helps people realise they have an issue?

Peter: Yes. People can have a hard time overlooking things, and there are a lot of small pushes–“You have problem if you smoke like this, or that much …”–every morning.

The participants highlight the repetition they are subjected to as something positive: in contrast to a one-shot message, such as a poster on the side of a bus, there are many “small pushes.”

For the participants who had stopped using cannabis, or had drastically reduced their abuse before they signed up, the messages appeared to function as s reminder:

Kenneth: Right until I signed up, I would smoke some cannabis. And I figured the messages helped me enormously, and reminded myself about all the things the cannabis did to me […] when I smoked.

I: Yes. And that helped, or what?

Kenneth: Yes, it helped, because if I had not received those messages, then it might be that I would have continued.

I: Did they make it easier for you to get through the day?

Niklas: Yes, in some ways.

I: How?

Niklas: The messages about what cannabis could do, for instance. You thought: it's a good thing I have quit, more or less.

The participants say the messages made them recall what it was like to abuse cannabis; and, in that sense, they were encouraged not to start again. These participants are in the maintenance phase: They need to stick to their decision, stay motivated, handle challenges, and muster the strength to resist temptation (Prochaska, DiClemente, & Norcross, 1992). Since the messages confirm that it was the right thing to stop, or to reduce the abuse, they help the participants maintain their motivation and stick to their decision.

Talking Culture and Passing on

Several participants say they have talked to others about the messages, and forwarded them to their acquaintances:

I: Have you talked to anybody about it? That you are enrolled.

Gert: I know quite a few people who have been involved in it. We have talked a lot about it.

I: Was it OK that there were more people involved in it, and that you were then able to talk about it?

Gert: Yes. And then we took them, and sent them on to others.

Line: It was very good to be able to forward some of the messages to my boyfriend, if you knew he was with some friends who smoked a lot.

Charlotte: I think it was good, because we then used to pass them on to others who smoke, to tell them it's wrong.

Forwarding text messages - jokes or picture messages, for instance - is common practice among young people (Laursen, 2006). Chain messages circulate among a group of friends and bind the group around a common experience, thereby creating a togetherness on which future interaction can be based. The Hashfacts/Restart messages are forwarded in the same way. This process of forwarding messages and talking about them may have a therapeutic effect, helping participants to formulate their thoughts, to understand their experiences and, perhaps, to change their behavior (Bolton, 2004).

Relationship to Other Counselling and Treatment Offers

The study revealed differences between the participants' views of traditional counseling and treatment and their opinions about the SMS offer. These differences depended on whether they had been (or still were) big abusers of cannabis, or were recreational users. The participants whose abuse of cannabis was major said personal treatment had been completely pivotal for them, and that the text messages would not be enough to stop them taking the drug:

Kenneth: But I also use the 12-step program to keep me from it, right?

I: OK. And what is that?

Kenneth: It is NA⁵. Attending a lot of meetings, and stuff like that. With that thing alone [the SMS program], I would not be able to do it. It is not enough. I must have something more.

Kenneth is a former abuser of cannabis, and has had counseling for his problem. At the time of the interview, he no longer abused cannabis. He says the SMS scheme is not enough, and expresses a need for further counseling and treatment.

The biggest group of receivers of Hashfacts and Restart, however, is young, recreational abusers of cannabis, and here another picture becomes evident. This group appears distanced from traditional counseling and treatment:

Kasper: Its not like SSP⁶. Them, you just laugh off.

Charlotte: You call some drug consultant, and you basically don't know who it is you are talking to.

I: Haven't you talked to a counselor or somebody in school? It could be a doctor or someone.

Niklas: No.

I: Have you considered it?

Niklas: Yes, but I was very much afraid that they would tell my parents or something like that.

These participants know about traditional counseling, but reject it (albeit in different ways and with different reasons). It is also characteristic of these recreational users that, unlike the big abusers, they do not believe they have a problem:

I: Would you make further changes to your cannabis abuse?

Karsten: No. I think–though I say it myself–that my use of cannabis is OK, the way I use it now.

Line: No, I don't think I need counseling because I am not like those cannabis abusers who need a bong to get up in the morning.

I: Now that we’re talking about your cannabis abuse, how much are you smoking nowadays?

Line: At the moment, I don't feel I am smoking too much: It's only at weekends. I'm trying to stop smoking together with my girlfriend and my best friend.

In these quotations, the participants say they do not see themselves as abusers who need counseling, even though they regularly abuse the drug. They appear to regard cannabis use as becoming problematic only when it is on a bigger scale, and their self-images do not fit with their visualizations of rehab centers and counseling. There are, however, small signs that the participants are concerned about their abuse: they have all signed up to a cannabis-related service, and they are reflecting on their drug use. The quotations from this group are often contradictory and full of changing attitudes–as shown by Line, in the example above, who in the space of a few moments says she does not need counseling yet also that she is trying to stop smoking. These participants are in the early stages of a transition process (Prochaska, et al., 1992). For them, the SMS service is an alternative offer that, on the face of it, demands less investment and is less demanding than traditional counseling and treatment:

Peter: It is much better. Phone counseling, like, demands an effort. You have to call between certain times […] It is easier to be a bit discreet about it. Instead of somebody calling and asking, “How are you today, then?” you just get an SMS.

Charlotte: If we now said that I had a problem with cannabis, then I would have more time to read an SMS than I would to call a counseling centre, or to go the Internet and seek information about it.

I: Is that too much?

Charlotte: Yes.

Conclusion

This article has outlined the participants' reception and use of two different SMS packages. The study has shown that the medium of SMS is suitable for informing young people about cannabis, and for giving them guidance. Generally, the participants see the messages as flexible and discrete, and as being personally meant for them, and they pay more attention to these messages than they do to mass approaches such as public information broadcasts on TV. However, the mode of approach and the way the messages are formulated are crucial to their reception. Concrete, straightforward, information-oriented messages are preferred to understanding, pedagogically formulated ones. The participants welcome facts partly because these provide them with new information and partly because they reinforce existing knowledge; guidance, counseling and predefined paths of progress, by contrast, are received with great skepticism.

To a great extent, the SMS messages helped participants in the process of change. Along with other factors, they motivated the participants to reduce their level of cannabis abuse or to maintain a reduced level. The repetition of the messages, and their serial nature, appeared to make a particularly strong contribution to the participants' growing reflections about and understanding of their situation. The study thus substantiates literature stating that raising awareness is an essential prerequisite of any transition process, and that a change of perspective often occurs when one gradually realizes that a change of behavior is necessary (Prochaska, et al., 1992).

The study has also shown that major abusers of cannabis see the SMS offer as a supplement to other forms of help. They point out that it is far from enough for them, with regard to changing their behavior. Participants whose use is recreational, however, see the SMS offer as attractive because it seems to be less obliging and less troublesome than traditional counseling and treatment. These users are in the early phases of the transition process, and are denying or seeking to minimize their abuse; or they are in the process of considering whether they have a problem, or what to do about one. At the same time, they distance themselves from established, traditional counseling and treatment routes, and do not see themselves as abusers, even though they take cannabis regularly. These are the very users who all too often have nowhere to go with their worries because their self-image does not fit with their imagined profile of a rehab/counseling centre, and because, with cannabis as a problem, they often encounter prejudice and moralizing. Providing information by SMS is a suitable way of making contact with this group.

The two main shortcomings of this study lay in the small interview group and the specific geographical and cultural setting. Nevertheless, given the accessibility and popularity of text messaging, further research exploring the potential of text messaging is advisable. There is a place for all types of helping, and it is paramount to capitalize on any request for information and counseling. Text message counseling seems to serve a unique purpose and has unique value. Further research on this topic should provide a clearer idea of which users could benefit from text message counseling and how services could be developed to different users. Practice guidelines that encompass the complexity and variety of user needs would be an important foundation for providers. Additionally, since the messages especially seem to have an impact operating with other agents, there is a need to explore the integration of SMS programs with other services.

Notes

1

http://web10334.web1.kuulalaakeri.fi/ (Finland), http://www.lasdrogas.info/index.php?op=InfoMovil (Spain), http://www.smash.name/ (Denmark).

2

For example: http://www.youthvoices.ca/ (Canada), http://www.paihdelinkki.fi/ (Finland), http://www.drugcom.de/ (Germany), http://www.dopinfo.no (Norway), http://www.netstof.dk (Denmark), http://www.freevibe.com/ (United States).

3

All names appearing in this article have been changed.

4

Niklas is probaply referring to the message Cannabis contains 420 chemical substances, 80 of which affect the psyche. In alcohol, by contrast,there is only one substance that affects the psyche.

5

Narcotics Anonymous.

6

SSP (The Team of School, Social service and Police, whose objective is to prevent crime among young people).